North
Counties Behavioral Support
Functional
Assessment Report
Consumer:
Calvin Harris
Date:
20 April 2000
DOB:
2/22/96
Consultant:
Lou Sandier
Method of Assessment: Calvin is a 4 year‑old
boy with primary diagnoses of non‑specific developmental delays and
autism based on assessments done by the Early Childhood Assessment Clinic
through the Child Development and Rehabilitation Center of Oregon Health
Sciences Hospital in Portland. The child lives with his parents, Tim and Kathy
Harris in Corvallis.
This
assessment is based on approximately 12 hours of direct contact with Calvin and
his family to include a single observation at his pre‑school placement. A
functional assessment interview (FAI) was completed with active input from both
parents and Calvin present at all times. This consultant also had direct
contact with Calvin during this period. In addition to his parents, others
contributing to this assessment included his pre‑school teacher, a
privately hired home tutor and a county autism specialist working with Calvin
at the school.
Reason for Referral: Calvin was referred to
North Counties for these services by the Benton County Health Department for
the purpose of generating a functional assessment (FA) of behavior towards the
provision of home‑based treatment recommendations. The three primary
behavioral issues identified by Mr. and Ms. Hands included: 1) being
cantankerous/moody; 2) throwing materials; and 3) tantrum/act out episodes.
During conversation, the parents also noted several other concerns. It was
reported that Calvin can go through periods of marked noncompliance during
which he will verbally oppose requests and directions by a loudly verbalized
"no'' or "I want to be all done." Such non‑compliance can
lead to spitting, passive resistance (ignoring verbal interactions/requests),
dropping to the floor and attempts to pull away. The parents also noted that
Calvin can be particularly prompt reliant. That is, despite his ability to
perform certain tasks/activities, he tends to wait for adults to facilitate or
otherwise directly support his actions. While sleep and toileting behaviors are
reported as improving, both areas will require further attention as well.
Description of Consumer: Calvin is a
delightful child who clearly enjoys the company of familiar adults. Despite an
initial presentation of being largely disengaged from his immediate
surroundings, Calvin appears to be generally aware and observant He also
readily identifies and remains generally responsive to familiar and caring
adults. This was observed both in the home as well as the school. During this
consultant's school contact, Calvin remained close to his aide and the autism
specialist interacting comfortably with them throughout The child also
initiated with his parents intermittently who were in the room at the time.
It
was also observed in the school, that even as he actively sought out and
engaged specific adults, Calvin was largely disengaged from his peers generally
taking his directions apart from teacher requests and whole class activity. In
fact, at one point, a child asked the autism specialist why Calvin had been
allowed to wash his hands early without first helping in the general clean up
going on and then waiting in line with the other students. While his ability to
respond to this focused attention has had important benefits, it will also be
particularly important for him too become more fully integrated across
classroom activities. In fact, the child's tendency to largely key in only on
selected adults for direction, feedback and general input may be one factor in
the above noted concerns around prompt reliance. The fact that Calvin is
reported to frequently become markedly escalated and particularly hard to
interrupt once his 1:1 aide leaves the classroom in the late morning may be
another indication of the need to re‑assess his routine separation from
the remainder of the class. A key will be to increasingly utilize this positive
1: 1 attention, direct support and training across pragmatic opportunities
throughout the day.
Mr.
and Ms. Harris have worked incredibly hard to provide both, a wide range of
experiences for their son along with daily specialized services meant to teach
those skills that have otherwise been delayed due to the autistic syndrome he
experiences. Particular emphasis has been placed on expressive and social
interactive skills. Based on report and the limited opportunities for
observation thus far, these teaching activities have been highly productive.
And while such direct instruction services should continue to be actively
incorporated into Calvin's day, the need to increasingly focus emerging skills
across naturally occurring circumstances throughout the day should be
emphasized
Per
parent report, Calvin’s typical day keeps him quite busy. He arrives at pre‑school
around 8:30am for a full day program that concludes with an additional two-hour
period of 1: 1 instruction from 3:30 to 5‑30. At home, further
instruction is often provided by both the parents as well as private tutors
hired by the family. Even while this framework has clearly benefited the child
via enhanced self‑expression, overall engagement and social interactive
tolerance, one issue to consider in such a structured format is the potential
for the child's emerging skills to come under the control of a very narrow
range of stimulus control conditions combined with the potential for the
learning of mis‑rules.
Direct
instruction strategies have clear benefits and wide application for children
with autism. They allow for the planned presentation of specific materials and
the ability to document the ability to teach to mastery. However, it is just as
important to then take the critical skills learned under such prescribed
conditions, and directly embed them across a wide range of naturally occurring
settings. Delays in doing this risks a greatly reduced ability to elicit
emerging skills across a range of functional and pragmatic conditions‑
Teaching the child to apply new expressive competencies across the day allows
for the natural 'trapping' of social reinforcers to include both, social praise
along with an increased ability to participate in a wider range of interesting,
motivating and reinforcing activities
For
instance, Calvin appeared to make several attempts to participate in peer activities
at the school, On each instance, however, his initial efforts were ignored by
peers and Calvin wound up either getting a bit rough with the kids or otherwise
compromising the activities in which they were engaged. While adult efforts to
facilitate Calvin's participation in games and like activities an valuable, he
will need to develop motivation over time to engage in such activities
independent of direct adult 'involvement. One more consideration is the need to
offer the child opportunities to participate in a range of social and community‑based
experiences in which those skills so effectively taught via direct instruction
strategies can be directly applied, generalized and enhanced by way of sharing
control and slowly expanding his range of daily choices.
A. Primary Behavioral Concerns ‑ definitions and
predictors
Cantankerous/moody:
This pattern was identified a s ranging from being 'spaced out'
(passive-resistance, non‑response, sucking thumb) and verbal opposition
to becoming completely disengaged and markedly oppositional. These sets of
behaviors are also noted as components of escalation to more intensive acting
out and aggressive episodes‑ While these episodes can be highly variable
from day to day, the family noted that they can occur at a rate of up to ten
times per day. Cantankerous episodes are most likely when the child is tired,
just after returning home from school, late afternoon and upon awakening from a
nap. It was also noted that the child becomes more likely to escalate to a full
tantrum should adults persist in attempts to do verbal corrections of the
behaviors. These episodes are less likely in the early morning, after dinner,
during pivotal response training types of activities and when Calvin is
actively engaged in preferred activities. Typical adult response has been to
present small edible treats for increased responsiveness, back off of
expectations and to decrease request.
Throwing: This behavior is identified as
the child's tendency to throw anything that he is either holding or can easily
gain access to during period of opposition or when he is otherwise
"angry.' Such anger was reported the result of being given lower
preference demands, being denied access to preferred tangibles and loss of an
expected reinforcer. Calvin may also throw during transitions from high to
lower preference activities. Typical adult responses have included having
Calvin pick up thrown objects and put them away and to lose access to the
object(s) for a day or two. Like the above identified problem behavior context,
throwing can either occur in isolation of other problem behaviors or be
reflective of an overall escalating behavioral chain leading to more intensive
physical opposition and/or acting out behaviors.
Act out/tantrum: This behavioral pattern is
defined as the child's engaging in at least one of the following behaviors:
screaming, kicking/hitting out, pulling away from the adult, and falling to the
floor/refusing to walk Throwing objects and other property destructive types of
behaviors along with persistent verbal and physical opposition are also likely
during these episodes. Like the first two behaviors above, the family noted
that while the occurrence of acting out can be highly variable through the
week. it, too, can occur up to 10 times per day. Act out behaviors are more
likely during 1: 1 instruction; when the parent leaves the home during while
the child is with an in‑home tutor; upon coming home from a community
trip and when asked to share (particularly around food). These episodes are
less probable during free play when the child is able to exercise choice and
while participating in pivotal response training activities.
Non‑compliance/opposition: "is
pattern is likely to represent a response class that is comprised of several
behaviors of concern. These include: being inconsolable (unable to comfort, re‑direct
or settle down); verbalized 'no' or 'I want to be done;' being demanding; and
spitting. Throwing, and the child's tendency to 'space out,' or become
obviously disengaged from the surrounding setting, am additional elements of
the response class. This grouping of behaviors also appears to be individual
elements of an escalating chain leading to more volatile and difficult to
interrupt physically and verbally disruptive behaviors. These behaviors are
more likely to occur during transitions, in high demand/low preference
conditions, during extended direct instructional episodes other then when
elements of pivotal response training are being incorporated; and when adults
continue to persist with demands and/or corrections despite the presentation of
low level disruptive behaviors (e.g., space out/thumb to mouth and verbalized
'no' in a normal speaking volume).
B. Health and Medical Factors: Calvin is
not taking any prescription medication at this time. Ms. Hams advised that she
does give him several vitamin and/or nutritional supplements each day. While
Calvin is reported to be in generally good health overall, his parents indicate
the potential for allergy related issues focused around dairy products. Further
testing has been scheduled.
C. Communication issues: Home efforts and
private tutoring has been heavily focused on language skills and Calvin has
reportedly been making steady progress over the past year regarding use of
language, Over several home contacts by this consultant the child self‑initiated
Short, clearly stated sentences to express wants/needs and in response to adult
comments. On several instances, brief exchanges were noted on the same topic.
Such sustained, on topic, conversation should be a continuing area of emphasis.
Direct instruction has largely focused on articulation and phonetics and has
had clear benefits for the child. Further objectives around this domain should
increasingly emphasize pragmatics and expression across a range of naturally
occurring conditions. Based on the limited contacts had by this consultant thus
far, Calvin appears to have a generally age appropriate receptive vocabulary.
His tendency to disengage, however, could give an impression of confusion
rather than the results of a lack of attention to the speaker, In this way, it
is important to have eye contact with the child prior to speaking to and/or
expecting a response from him Doing 'check‑ins" from time to time to
be certain of his comprehension and level of engagement would also be
suggested.
D. Lifestyle assessment: Calvin is an
active and happy child who attends a regular pre‑school class five days
each week and regularly enjoys time in the community with family and other
adults. In fact, Mr. and Ms. Harris reported that while community trips
continue to be an area of concern, Calvin has been making steady progress in
this domain over the past year. Due to persisting problems around social
interactive skills, particularly with poem the child has been more limited ‑in
his contacts with other children. As noted above,‑ his real desire
towards but uncertainty regarding how to interact with peers, was observed
during the single school visit. Calvin's several clew efforts to engage other
children were sincere but inefficient which lead to his either being a bit
rough (pushing) with them or impeding their efforts to continue using specific
materials. Calvin's motivation to engage peers is a definite strength which
should be strongly supported and enhanced. Due to the planned nature of his
typical weekday, Calvin may often find himself with little opportunity to
influence his schedule and overall activities. The fact that he frequently
returns home after school in a 'grumpy' and more generally escalated state may,
in part, represent a need to consider the interposition of less structured
social experiences that could also actively serve to assist with the
generalization and maintenance of his actively emerging social, adaptive and
functional skills.
E. Functional assessment summary & impressions:
Calvin has clearly made substantial progress since the initiation of direct
instructional strategies across home and school settings. A particular value of
direct instructional approaches is their ability to allow a clear focus on
needed skills and the ability to clearly document the attainment of mastery on
those skills. With this, however, one specific consideration is the fact that
such a structure often reduces opportunities to apply and develop those skills
across pragmatic settings. One risk in this regard is the potential for those
skills to come under too narrow a set of stimulus control conditions.
In
other words, elicitation of new skills may only be likely under those very
specific circumstances under which the learning occurred. Discrimination of
when and when not to apply these skills may be missed.
A
second consideration is the potential for the occurrence of behavioral mis‑associations.
This can result as the child incorrectly pairs irrelevant external stimuli with
specific individual behavioral production. Calvin's reported tendency to be
overly reliant on adult prompting and direction may be an example of this
dynamic. A final issue is the child's potential to learn misrules. This focuses
on the potential for an over generalized application of training conditions
across the day. A possible example of this last dynamic might be seen in the
child's demands during the school day to do 'work' rather than be a part of the
class. Such unmet demands are a likely antecedent to escalation and might be
contributing to the motor bursts reported after I ‑ I has left the
classroom for the morning and Calvin is unable to otherwise escape school
expectations.
The
intensity of his daily schedule might also be an additional component driving
some of the afore noted problem behaviors. This may be represented in the fad
that the child is reported to consistently return home at the end of his day
irritable and generally oppositional. It was also noted that he tends to be
more resistant during extended 1: 1 sessions in the home. Moreover, that Calvin
tends to be more responsive and less escalated during specific periods where
his schedule is less intense and/or he has specific opportunities to influence
and more naturally participate may also lend credence to this hypothesis. Such
periods include after dinner at home, during free play opportunities and when
engaged in pivotal response training types of activities. Calvin's preference
for a PRT approach may be due to its emphasis on the child's ability to
directly influence the particular learning activities and tendency to engage in
more naturally motivating and reinforcing conditions.
Based
on this assessment process, specific problem behaviors appear linked to
(a) functional
skill deficits (expressive communication/protest; social interactive skills; sustained
attention; and self‑management/regulation);
(b) functional
relationships (escape; social attention; access to preferred tangibles);
(c) reduced
opportunities for adult supervised community experiences and general peer
contacts;
(d) limited
opportunities to exercise shared control/influence across the day; and
(e) generalization
problems.
Environmental conditions that appear more predictive of
subsequent problem behaviors:
(a) high/low
preference transitions;
(b) tired/after
a nap;
(c) late
afternoon;
(d) denied
tangible demands;
(e) demand
situations;
(f) losing
access to an expected reinforcer;
(g) during
1: 1 instruction;
(h) expectations
to share (especially food); and
(i) repeated
verbal interrupts/corrections by adults.
Pre‑curser
behaviors, or those that often precede more challenging episodes include:
persistent thumb sucking verbalizing 'no' arid/or 'I want to be done;' head in
lap/hands, resistance to routinely done activities; hand flapping; persistent
demands,, indifference to normally preferred reinforcers/activities and
increased disengagement
General Recommendations:
Lou
Sandler, MS
Behavioral
Consultant
North
Counties Behavioral Support